Chiari I malformation associated with atlanto-occipital assimilation presenting as orthopnea and cough syncope: a case report and review of literature.

Although it is not uncommon for patients with Chiari I malformations to present with respiratory complaints, cough syncope is a rare presenting symptom. We report an adult patient who harbored both a Chiari I malformation and atlanto-occipital assimilation who complained of cough syncope, orthopnea, and central sleep apnea. The patient underwent decompressive craniectomy of the posterior fossa and cervical level 2 laminectomy. However, due to a possible initial underappreciation of the profound narrowing of the foramen magnum as a result of these concomitant pathologies, the patient may have had continued impaired cerebrospinal fluid flow, leading to a symptomatic pseudomeningocele and requiring a more extensive decompression that included a cervical level 3 laminectomy as well as a temporary lumbar drain. On 2-year follow-up, he has remained asymptomatic.

Iatrogenic traumatic intracranial aneurysm after endoscopic sinus surgery.

Iatrogenic traumatic intracranial aneurysms are rare, but their clinical impact is significant secondary to their risk of intracranial hemorrhage and in their frequent complexity in management. We report an adult patient with a history of chronic sinusitis who, while undergoing elective endoscopic polypectomy, suffered an iatrogenic injury to an A2 segment branch of the left anterior cerebral artery, resulting in a pseudoaneurysm. Management included endovascular coiling and a bicoronal craniotomy approach, using a split-thickness cranial graft and abdominal fat graft to repair the associated left cribriform plate defect.

Chiari I malformation associated with atlanto-occipital assimilation presenting as orthopnea and cough syncope.

Although it is not uncommon for patients with Chiari I malformations to present with respiratory complaints, cough syncope is a rare presenting symptom. We report an adult patient who had both a Chiari I malformation and atlanto-occipital assimilation, and complained of cough syncope, orthopnea, and central sleep apnea. The patient underwent decompressive craniectomy of the posterior fossa and a cervical level 2 laminectomy. However, due to an initial under-appreciation of the profound narrowing of the foramen magnum as a result of these concomitant pathologies, the patient had continued impaired cerebrospinal fluid flow, leading to a symptomatic pseudomeningocele and required a more extensive decompression that included a cervical level 3 laminectomy as well as a temporary lumbar drain. On 2 year follow-up, he remained asymptomatic.

Initial Experience with Neuroform EZ in the Treatment of Wide-neck Cerebral Aneurysms.

PURPOSE: Stent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported. MATERIALS AND METHODS: Seventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed. RESULTS: In all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm. CONCLUSION: The Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.

Frontal sinus schwannoma: case report and review of literature.

Although schwannomas are frequently found in the head and neck region, sinonasal tract involvement is extremely rare, especially those of the frontal sinus. We report a patient with an incidentally found right frontal sinus lesion. The patient underwent resection of the tumor via a right craniotomy. The histological diagnosis was consistent with a schwannoma. There has been no radiographic recurrence on 2-year follow-up.

Major intratumoral hemorrhage of a petroclival atypical meningioma: case report and review of literature.

Spontaneous intratumoral hemorrhage associated with a meningioma is an extremely rare event and has a very high rate of morbidity and mortality. We report a patient with a history of subtotal resection of a petroclival meningioma followed by gamma knife radiosurgery who presented with sudden neurological deterioration following intratumoral hemorrhage after 4 asymptomatic years. The patient underwent early resection of this atypical meningioma and evacuation of hematoma via a retrosigmoid transpetrosal approach and had rapid neurological improvement.

Hydrocephalus in posterior fossa lesions: ventriculostomy and permanent shunt rates by diagnosis.

OBJECTIVES: The rate of ventriculostomy for acute hydrocephalus and progression to shunt-dependent chronic hydrocephalus in patients with posterior fossa lesions are not well known. METHODS: We retrospectively reviewed 104 consecutive cases with posterior fossa lesions on admission to the University of Illinois Hospital from June 2002 to December 2005. We recorded the rate of ventriculostomy and permanent ventricular shunting, which were compared among etiologic groups, using chi-squared and Fisher's exact tests. RESULTS: Overall, 35 patients had ventriculostomy for acute hydrocephalus and 16 had permanent shunting for shunt-dependent chronic hydrocephalus. Of those with primary posterior fossa intracranial hemorrhage (ICH) (42 cases), 19 (45%) required ventriculostomy, with five (26%) requiring subsequent permanent shunting; 13 patients had hematoma evacuation, with two having permanent shunting. Of those with cerebellar infarction (14 cases), four (29%) required ventriculostomy and one (25%) had a permanent shunt; two had a decompressive craniectomy. Of those with neoplasms (43 cases, 33 surgically resected), ten (23%) required ventriculostomy and nine (21%) required permanent shunting. In addition, two of the three cases with infectious processes required ventriculostomy and one required a permanent shunt. In-hospital mortality was 21% (9/42 cases) for patients with ICH, 14% (2/14 cases) for patients with infarction and 0% for all others. DISCUSSION: Acute primary posterior fossa hemorrhage has the highest rate of ventriculostomy for acute hydrocephalus and highest inpatient mortality but a surprisingly low rate of permanent shunt-dependency. When hydrocephalus was caused by a neoplasm, there was a higher rate of permanent shunt placement.